fertility news

It is estimated that 800,000 men and women in their reproductive years will be diagnosed with cancer and many have concerns about their fertility. Yet many oncologists, according to an expert panel convened by the American Society of Clinical Oncology (ASCO), either do not discuss the possibility of infertility resulting from cancer treatment or do a poor job discussing a patient’s options for preserving their fertility. As one cancer specialist noted, “Now with early detection and better treatment we are increasing the number of cancer survivors and for many issues of fertility arise”.

To help doctors provide the best care possible ASCO asked the experts they brought together to identify and develop recommendations for fertility preservation in cancer patients and these guidelines for clinical practice were published in May 2006. The ASCO guidelines state that, “As part of education and informed consent before cancer therapy, oncologists should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists.” They encouraged the doctors to have this discussion at the earliest possible opportunity and provided evidence that because the issue was of great important to patients, addressing the issue, “was a positive factor in patients coping emotionally with cancer.” Not all cancer treatments affect fertility and if they do the infertility may be temporary. It is important to note that sperm production in men is continuous whereas women are born with their lifetime supply of eggs and do not produce any more. According to ASCO, cancer treatment can lead to infertility depending on the following factors:

• The type and dose of the chemotherapy drug and how it’s given (by mouth, injection or intravenously)
• The dose of radiation given and the area that is being irradiated
• The type of cancer
• The patient’s age and gender
• Whether the patient had fertility problems before cancer treatment

The greatest damage comes from radiation to the ovaries or testicles and when cancer drugs in the “alkylating agent” category are used, according to the American Society for Reproductive Medicine (ASRM) . Alkylating agents directly damage DNA to prevent the cancer cell from reproducing. Two drugs in this category are cisplatin and carboplatin.

Fertility preservation options that are available before cancer treatment depend on the type of cancer and a patient’s personal preference. Many of the newer techniques are investigationalthey are still being tested; they may not be available to all patients; and they may be available in just a few fertility centers. The following is a partial list of the fertility preservation options available before starting treatment by gender:

Women

Embryo Cryopreservation:
Eggs are harvested and inseminated in a dish (in vitro fertilization or IVF). The embryos that result are frozen for later use. This is the most established technique but it may not be an option for women without a partner, women who cannot delay treatment long enough to stimulate the ovaries with the fertility drugs needed to produce multiple eggs, or in women with tumors that are hormonally responsive to fertility drugs such as breast cancers.

Oocyte (Egg) Cryopreservation:
Unfertilized eggs are harvested and frozen for later use. This technique is investigational and only a few babies have been born using it. It is also expensive, invasive and may not be an option for women who cannot delay treatment, or in women with tumors that are hormonally responsive.

Oophoropexy (Ovarian Transposition):
The ovaries are surgically moved out of the field of radiation. This technique does not help women who need chemotherapy.

Ovarian Tissue Cryopreservation:
Ovarian tissue, containing thousands of immature eggs, is surgically removed, frozen and reimplanted after treatment. This is an investigational technique limited to women in their 20s and early 30s. Although the tissue may survive and function, many eggs may be lost in the freezing process and there is the possibility (although remote according to most oncologists) that cancer cells can be transmitted back into the body.

Ovarian Suppression:
This technique uses hormone therapy in the form of birth control pills or Gonadotropin-releasing hormone (GnRH) agonists among others to protect the eggs against chemotherapy and radiation. This is an investigational approach with limited data on its effectiveness.

Men

Sperm Cryopreservation:
Semen samples are frozen at a sperm bank or fertility center for later use before starting treatment. The sample is usually produced by masturbation however other methods such as testicular extraction may be used. Like embryo freezing this is the most established technique available. Samples can be stored for years and if the sperm counts are low or the supply is limited the chances for conception can be increased by using assisted reproductive technology (ART). These include IVF with intracytoplasmic sperm injection (ICSI), an assisted fertilization procedure where one sperm is injected directly into the egg.

Testicular Tissue Cryopreservation:
Testicular tissue, containing thousands of immature sperm is surgically removed, frozen and reimplanted after treatment. This is an investigational technique.

Testicular Suppression:
Like ovarian suppression, hormone therapy is used to protect the gonads. This investigational option has not been successful.

Sperm production may recover after cancer treatment however it may take several years. If the counts are low IVF-ICSI is a good option for achieving pregnancy.

ASCO cautions patients that it is difficult to make decisions about fertility preservation options at the time of their cancer diagnosis. They suggest keeping the following points in mind:

1. When discussing cancer treatment with your doctor be sure to ask if you are at risk for treatment-related fertility problems; let them know if you are concerned about preserving your fertility.
2. Have this discussion with your doctor as soon as possible since some options require additional time to perform.
3. Although the data collected so far are limited, most fertility preservation methods do not appear to increase the risk of the cancer returning even in cancers that are hormone sensitive.
4. Having a history of cancer, cancer treatment, or fertility preservation treatment does not appear to increase the risk of cancer or birth defects for future children. However, patients with a hereditary genetic syndrome and women whose children were exposed to chemotherapy while in the uterus may be at higher risk for developing cancer or birth defects.
5. Ask your doctor for counseling referrals or the support services available if treatment related infertility is making you anxious.

There are many resources available to patients that didn’t exist even a few years ago. Fertile Hope for instance, is a patient advocacy group started in 2001 by Lindsay Nohr Beck as a result of her own endeavors to preserve her fertility in the face of critical cancer treatments. The group is a national, nonprofit organization dedicated to providing reproductive information, support and hope to cancer patients and survivors whose medical treatments present the risk of infertility. Fertile Hope is dedicated to helping these patients through programs and services in the following five areas:

• Awareness
  Increase awareness of fertility risks and preservation options among medical, patient and lay communities.
• Education
  Provide credible, accurate educational resources to enable educated medical advice and patient decisions.
• Financial Assistance
  Provide fertility preservation financial assistance options for patients whose medical treatments threaten reproductive function.
• Research
  Advance fertility preservation technologies through research grants.
• Support
  Provide support to help patients cope with the physical and emotional issues associated with infertility, fertility preservation, assisted reproduction, family planning, genetic counseling, pregnancy, adoption and other related issues.

Visit these websites for additional information on this topic:

For the ASCO Patient Guide that includes a list of questions to ask your doctor and links to other resources for cancer patients visit their website at:
http://www.plwc.org/PLWC/ASCO%20Resources/Fertility_Patient_Guide_FINAL_5.1.06.pdf

ASRM Patient Fact Sheet: Cancer and Fertility Preservation. Available at: http://www.asrm.org/Patients/FactSheets/cancer.pdf

Fertile Hope: http://fertilehope.org/

The InterNational Council on Infertility Information Dissemination (INCIID): http://www.inciid.org/index.php

References:

1. ASRM Patient Fact Sheet: Cancer and Fertility Preservation. Available at: http://www.asrm.org/Patients/FactSheets/cancer.pdf
2. ASCO Recommendations for Fertility Preservation in Cancer Patients. J Clinical Oncology. 2006; 24: 2917-31.
3. Fertility guidelines addresses often-ignored treatment side effect. CA: A Cancer Journal for Clinicians 2006; 56: 251-53.
4. FertileHope.org. Available at: http://fertilehope.org/